<#include "common/templet.html"/> <@layout>
<div class="container">
	<div class="page-header">
		<h2>维护信息</h2>
	</div>
	
	<div class="row row-offcanvas row-offcanvas-right ">
		<form class="form-horizontal" action="${ctx!}/admin/save" method="post">
		<div class="panel panel-default">
		  <div class="panel-heading">新三大目录药品编码表</div>
		  <div class="panel-body">
  			<div class="form-group">
				<label for="three.code" class="col-sm-2 control-label">医疗项目编码</label>
				<div class="col-sm-10">
					<input type="text" class="form-control" id="three.code"
						name="three.code" placeholder="医疗项目编码" 
						value="${three.code!}">
				</div>
			</div>
			
			<div class="form-group">
				<label for="three.name" class="col-sm-2 control-label">医疗项目名称</label>
				<div class="col-sm-10">
					<input type="text" class="form-control" id="three.name"
						name="three.name" placeholder="医疗项目名称" 
						value="${three.name!}">
				</div>
			</div>
			
			<div class="form-group">
				<label for="three.type" class="col-sm-2 control-label">医疗项目分类</label>
				<div class="col-sm-10">
					<input type="text" class="form-control" id="three.type"
						name="three.type" placeholder="医疗项目分类" 
						value="${three.type!}">
				</div>
			</div>
			
			<div class="form-group">
				<label for="three.payedGrade" class="col-sm-2 control-label">报销等级</label>
				<div class="col-sm-10">
					<input type="text" class="form-control" id="three.payedGrade"
						name="three.payedGrade" placeholder="报销等级" 
						value="${three.payedGrade!}">
				</div>
			</div>
			
			<div class="form-group">
				<label for="three.price" class="col-sm-2 control-label">单价</label>
				<div class="col-sm-10">
					<input type="text" class="form-control" id="three.price"
						name="three.price" placeholder="单价" 
						value="${three.price!}">
				</div>
			</div>
			
			<div class="form-group">
				<label for="three.price" class="col-sm-2 control-label">单位</label>
				<div class="col-sm-10">
					<input type="text" class="form-control" id="three.unit"
						name="three.unit" placeholder="单位" 
						value="${three.unit!}">
				</div>
			</div>
			
			<div class="form-group">
				<label for="three.standard" class="col-sm-2 control-label">规格</label>
				<div class="col-sm-10">
					<input type="text" class="form-control" id="three.standard"
						name="three.standard" placeholder="规格" 
						value="${three.standard!}">
				</div>
			</div>
			
				<div class="form-group">
				<label for="three.reagentType" class="col-sm-2 control-label">剂型</label>
				<div class="col-sm-10">
					<input type="text" class="form-control" id="three.reagentType"
						name="three.reagentType" placeholder="剂型" 
						value="${three.reagentType!}">
				</div>
			</div>
					
			<div class="form-group">
				<label for="three.selfPercent" class="col-sm-2 control-label">自费比例</label>
				<div class="col-sm-10">
					<input type="text" class="form-control" id="three.selfPercent"
						name="three.selfPercent" placeholder="自费比例" 
						value="${three.selfPercent!}">
				</div>
			</div>
			
			<div class="form-group">
				<label for="three.limitPrice" class="col-sm-2 control-label">限价标记</label>
				<div class="col-sm-10">
					<input type="text" class="form-control" id="three.limitPrice"
						name="three.limitPrice" placeholder="限价标记" 
						value="${three.limitPrice!}">
				</div>
			</div>	
			
			<div class="form-group">
				<label for="three.heightLimitPrice" class="col-sm-2 control-label">最高限价</label>
				<div class="col-sm-10">
					<input type="text" class="form-control" id="three.heightLimitPrice"
						name="three.heightLimitPrice" placeholder="最高限价" 
						value="${three.heightLimitPrice!}">
				</div>
			</div>
			<div class="form-group">
				<label for="three.provinceLimitPrice" class="col-sm-2 control-label">省级限价</label>
				<div class="col-sm-10">
					<input type="text" class="form-control" id="three.provinceLimitPrice"
						name="three.provinceLimitPrice" placeholder="省级限价" 
						value="${three.provinceLimitPrice!}">
				</div>
			</div>	
			
			<div class="form-group">
				<label for="three.cityLimitPrice" class="col-sm-2 control-label">市级限价</label>
				<div class="col-sm-10">
					<input type="text" class="form-control" id="three.cityLimitPrice"
						name="three.cityLimitPrice" placeholder="市级限价" 
						value="${three.cityLimitPrice!}">
				</div>
			</div>		
			
			<div class="form-group">
				<label for="three.countyLimitPrice" class="col-sm-2 control-label">县级限价</label>
				<div class="col-sm-10">
					<input type="text" class="form-control" id="three.countyLimitPrice"
						name="three.countyLimitPrice" placeholder="县级限价" 
						value="${three.countyLimitPrice!}">
				</div>
			</div>		
			<div class="form-group">
				<label for="three.villageLimitPrice" class="col-sm-2 control-label">乡级限价</label>
				<div class="col-sm-10">
					<input type="text" class="form-control" id="three.villageLimitPrice"
						name="three.villageLimitPrice" placeholder="乡级限价" 
						value="${three.villageLimitPrice!}">
				</div>
			</div>
			
			<div class="form-group">
				<label for="three.bedPrice" class="col-sm-2 control-label">不合理费用标志</label>
				<div class="col-sm-10">
					<input type="text" class="form-control" id="three.bedPrice"
						name="three.bedPrice" placeholder="不合理费用标志" 
						value="${three.bedPrice!}">
				</div>
			</div>	
			
			<div class="form-group">
				<label for="three.remark" class="col-sm-2 control-label">备注</label>
				<div class="col-sm-10">
					<input type="text" class="form-control" id="three.remark"
						name="three.remark" placeholder="备注" 
						value="${three.remark!}">
						
					<input type="hidden" name="three.id" value="${three.id!}">	
				</div>
			</div>				
		  </div>
		</div>
		
		<div class="panel panel-default">
		  <div class="panel-heading">限制性药品用药编辑</div>
		  <div class="panel-body">
		 	 <div class="form-group">
				<label for="three.code" class="col-sm-2 control-label">项目代码</label>
				<div class="col-sm-10">
					<input type="text" class="form-control" id="three.code"
						name="limit.code" placeholder="项目代码" 
						value="${limit.code!}">
				</div>
			</div>
			
			<div class="form-group">
				<label for="limit.name" class="col-sm-2 control-label">中文名称</label>
				<div class="col-sm-10">
					<input type="text" class="form-control" id="limit.name"
						name="limit.name" placeholder="中文名称" 
						value="${limit.name!}">
				</div>
			</div>
			
			<div class="form-group">
				<label for="limit.type" class="col-sm-2 control-label">分类</label>
				<div class="col-sm-10">
					<input type="text" class="form-control" id="limit.type"
						name="limit.type" placeholder="分类" 
						value="${limit.type!}">
				</div>
			</div>
			
			<div class="form-group">
				<label for="limit.reagentType" class="col-sm-2 control-label">剂型</label>
				<div class="col-sm-10">
					<input type="text" class="form-control" id="limit.reagentType"
						name="limit.reagentType" placeholder="剂型" 
						value="${limit.reagentType!}">
				</div>
			</div>
		  
		  
		  <div class="form-group">
				<label for="limit.limit" class="col-sm-2 control-label">限制</label>
				<div class="col-sm-10">
					<input type="text" class="form-control" id="limit.limit"
						name="limit.limit" placeholder="限制" 
						value="${limit.payedGrade!}">
				</div>
			</div>
			
			<div class="form-group">
				<label for="limit.payedGrade" class="col-sm-2 control-label">备注</label>
				<div class="col-sm-10">
					<input type="text" class="form-control" id="limit.remark"
						name="limit.remark" placeholder="备注"
						value="${limit.remark!}">
						
						<input type="hidden" name="three.id" value="${three.id!}">
				</div>
			</div>
		  </div>
	 	</div>
		
		<div class="form-group" align="center">
			<div class="col-sm-offset-2 col-sm-10">
				<button type="submit" class="btn btn-primary">保存</button>
				<a type="button" class="btn btn-default" href="javascript :;"
					onClick="javascript :history.back(-1);">返回</a>
			</div>
		</div>
		</form>
	</div>
</div>

</@layout>
